Patient safety repeated this year as a prominent theme
of the scientific sessions of the Annual Meeting of the American Society
of Anesthesiologists October 17-21 in New Orleans. In six sessions, there
were 89 individual scientific presentations.

Two papers were presented which raised concern about the
potential for epidural catheter contamination. The first was offered by
Drs. P. Langevin, P. Guley, and N. Gravenstein of the University of Florida
at Gainesville. Their in-vitro study indicated that bacteria are not likely
to migrate more than eight inches along a catheter from the point at which
it is externally contaminated and that immersion of the catheter in betadine
for three minutes followed by air drying for three minutes effectively
sterilized it. They conclude that if the lower connector of an epidural
catheter becomes inadvertently disconnected subjecting the catheter to
potential contamination, it is probably safe to reconnect it if at least
eight inches of the catheter is cut away using sterile technique and the
cut end is treated with betadine as above. A related paper from Dr. M.
Dailey, et al. of the Medical University of South Carolina presented a
compilation of reports of epidural abscesses after epidural blockade. Their
data, which included all reported cases of epidural abscess in the last
15 years, revealed 13 infections, all occurring in patients who had the
catheters placed for pain control outside of the OR environment. These
two reports emphasize the necessity for employing aseptic technique when
placing epidural catheters.

Dr. 0. Hendon, et al. of the University of California
at San Diego presented data from confidential questionnaires indicating
that anesthesiologists

have a higher incidence of sleep disturbances than the
general population. Cumulative sleep debt and poor quality sleep have the
potential to hamper performance of anesthesia personnel. In a companion
paper, they reported that 75% of 85 subjects drank alcohol on a regular
basis, that 10% of the subjects had at least once been hung over while
administrating anesthesia, and 40% administered anesthesia within 12 hours
of alcohol consumption. Sixty-three percent of the anesthesia providers
admitted to having ever used marijuana. Four of 38 respondents admitted
to using other controlled substances including cocaine, benzodiazepines,
opiates, hallucinogens, amphetamines and N20. One subject reported that
he had lost consciousness during administration of anesthesia due to an
overdose of midazolam. Sixteen percent of the subjects said that they had
seriously contemplated suicide yet no one admitted actually attempting
it. Taken together, the studies appear to indicate a significant incidence
of substance abuse and mental disturbance among anesthesia personnel. (See
Letter to the Editor, pg. 51.)

Drs. M. Hartmannsgraber and N. Gravenstein of the University
of Florida reported a study indicating that a commercially available air
eliminator supplied with a blood warmer/rapid infuser was not effective
in removing large volumes of air and did not eliminate the need for rigorous
air elimination from the system prior to clinical use.

Dr. R. Keenan and associates from the Medical College
of Virginia reported on their study of bradycardia during anesthesia in
infants. Their enquiry focused on the incidence and influencing factors
on this relatively common and serious problem. They found that the likelihood
of bradycardia (defined as baseline) was increased in sicker infants undergoing
emergency procedures of longer duration. Independent of these variables,
bradycardia was 2.2 times more likely when infants were attended by non-pediatric
anesthetists than by their pediatric counterparts.

Two papers addressed the use of nitrous oxide for patients
undergoing bone marrow harvest. Dr. D. Fausel and associates from the Cleveland
Clinic Foundation examined the influence of nitrous oxide (during anesthesia
for the donor) on time to bone marrow engraftment in recipients. They found
that exposure to this agent had no significant influence on this time.
Dr. G. Lederhaas and coworkers at Stanford University examined bone marrow
viability as assessed by colony forming unit-granulocyte macrophage assay
(CFU-GM) and found that human bone marrow exposed to nitrous oxide experienced
no significant difference in viability. Both papers concluded that use
of nitrous oxide in patients undergoing bone marrow donation is not contraindicated.

Dr. J. Gross and colleagues from the University of Connecticut
examined the effects of midazolam and diazepam on SaO2 during conscious
sedation. Using a randomized, double-blind study technique on 86 patients,
they found that equi-sedating doses of these two drugs significantly reduced
SaO2 for up to 80 minutes, and that there were no significant differences
between the drugs at any time during

the study period. Both drugs caused SaO2 to fall below
85% in some patients breathing room air. They concluded that midazolam
(compared to diazepam) did not appear to increase the risk of hypoxemia
during conscious sedation, but that both held the potential to cause significant
desaturation. They emphasized the need for careful monitoring of patients
sedated with either drug.

Hct Doesn't Help

Dr. M. Bodner and associates at Washington University
in St. Louis examined the relationship between cardiovascular morbidity
and perioperative hematocrit (Hct) in patients undergoing radical prostatectomy.
They found that there was no significant difference in the lowest documented
Hct in patients who had cardiovascular morbidity and those who did not,
thus negating the predictive value of patient hematocrit. With increasing
awareness of viral transmission during blood transfusion, this study would
support a more cautious approach to transfusion timing.

Two presentations dealt with patient recall during anesthesia.
The first, by Dr. M. Clemency and associates of Emory University, examined
the incidence of recall of surgery following anesthesia for trauma. They
found an overall rate of recall of 5% (less than in previous studies in
this patient population), but when data were stratified by .minutes without
anesthesia' the results showed (not unsurprisingly) that those patients
with more than 15 minutes of no anesthesia had a higher incidence of recall
than those with less (33% vs. 2%). Surprisingly, the incidence of recall
did not appear to be influenced by the use of amnestics, although numbers
examined were quite small. They urged further study of the effectiveness
of amnestics in anesthesia for trauma. The second study, by Dr. W. Gild
(University of Washington, Seattle) and associates in the Closed Claims
Project, examined liability aspects of recall following surgery and unintentional
administration of muscle relaxants to awake patients. They found a 2% incidence
of recall and awake paralysis in the Closed Claims Data Base (n m 2400).
Thirty-three of the claims involved recall of intraoperative events (recall),
while 12 resulted from unintentional administration of muscle relaxants
to awake patients (awake paralysis). Award amounts for all these claims
were significantly less than for other claims in the data base ($10K vs.
$95K), standard of care was judged (by peers) to have been met less frequently
in the awareness claims than others (24% vs. 44%), and no consistent pattern
of causation could be discerned in the recall subgroup of claims. The awake
paralysis claims involved simple lapses of vigilance and carelessness.
The study underscores present lack of understanding of the etiology of
the awareness and recall of events during general anesthetics.

Dr. B. McGrath and coworkers at George Washington University
studied the incidence of pulmonary embolization from pneumatic tourniquet
use during orthopedic surgery using transesophageal echocardiography. Evidence
of 'solid' emboli was seen in 5 of the 22 patients studied (all following
deflation of the tourniquet). Patients with embolization suffered no significant
changes in BP or 02 saturation. They found that embolization following
deflation of lower leg tourniquet is a relatively common event (23%) and
was seen independent of whether marrow cavities were entered. They thus
concluded that the solid emboli seen were venous thrombi and called for
further study to determine the nature and significance of emboli and the
potential effectiveness of anti-thrombus prophylaxis.

Predicting Difficult Intubations

Dr. J.S. McDonald and colleagues from Ohio State University
studied 1,501 patients who underwent laryngoscopy and intubation. In each
of these patients, visualization during laryngoscopy was graded on a scale
of 1-4 (I being good visualization and 4 being very poor). They then recorded
eight factors on each patient to see if the difficult intubations could
be predicted from these physical signs. The factors included: visualization
of tonsillar pillars, mentum-suprahyoid distance, mentum-sternal notch
distance, oral opening distance, range of neck motion, body habitus, receding
mandible, and buck teeth. These characteristics were scored on a form during
the preoperative visit. Seventy-nine patients (5.3%) were felt to have
a larynx that was difficult to visualize (Grade 3) and 23 patients (1.5%)
were felt to have a larynx that was very difficult to visualize (Grade
4). Several different analyses performed to determine if there was a relationship
between any single factor or group of factors and the visualization score
failed to reveal any consistent relationship. The authors also noted that
12 cases (1%) had oxygen saturations of less than 90%. They concluded that
anatomic scoring methods used to prospectively predict difficult intubations
are largely unreliable as screening tools.

Fire in the Operating Rooms

Dr. R. Westerlund from New York University Medical Center
reported on the problems encountered when a fire broke out during a neurosurgical
procedure when a hand-held laser was accidentally discharged while aimed
at the operating room drapes. The fire produced dense acrid smoke that
forced everyone out of the room in less than two minutes. The patient was
fixed to the table with pins and could not be moved, and visibility in
the room was near zero.

In reviewing the experience, the author developed some
important general guidelines. First, do not assume that a fire cannot occur
in your operating room. Instead plan ahead and think about what would have
to be done if a fire did take place. It is important to know the types
and locations of fire extinguishers in the operating room, as different
fire extinguishers have different uses. For instance, halon can be used
around electronic equipment, but it consumes oxygen in the room. Carbon
dioxide leaves granular particles. The locations of alarm boxes, gas shut
off valves, and emergency equipment should be known by all personnel. Auxiliary
lighting, such as flashlights, and fire blankets should be available.

Some general safety precautions should also be followed.
There should be stringent rules for control of sources of ignition (i.e.,
lasers, electrocautery and hot fiberoptic cords). Keep ignition sources
away from flammable solutions and combustible material. Use of laser-resistant
drapes should be encouraged during these cases. Plan how to remove burning
drapes, covers and clothing. Pouring water on an impervious drape will
not extinguish the fire as it will continue to burn on the underside of
the drape. In these cases, it is necessary to remove the drapes and then
attempt to extinguish the fire. It should not be assumed that the fire
is entirely out until the entire area is thoroughly inspected.

Personnel should be prepared to react in the presence
of heavy acrid smoke. It should not be assumed that one can function normally
in the presence of a smoke filled room, as the heavy smoke may make it
impossible to see or breathe. During a fire, personnel may be forced to
leave the O.R. without being able to help the patient. Do not assume that
the ventilation system will clear the smoke. Most ventilation systems have
smoke detectors which shut off the exhaust to that room in the event of
a fire. Care for the anesthetized patient in a hazardous environment is
something that requires a great deal of advanced preparation.

Lower Extremity Nerve Injury in the Lithotomy Position

Drs. M. Warner and J. Martin of the Mayo Clinic reviewed
more than 1,000,000 entries in the Mayo Clinic database of surgical cases
performed from 1957-1992 to try to determine the incidence of lower extremity
nerve injury in the lithotomy position. The records were scanned for 56
surgical procedures historically done in the lithotomy position, resulting
in 198,000 cases which were further examined using ICD*2*CM diagnosis codes
for 26 different nerve injuries and four compartment syndromes. To be classified
as a persistent nerve injury, a motor deficit had to be present for greater
than three months' duration, and the compartment syndrome was defined as
the presence of the diagnosis plus fasciotomy.

The authors found 922 patients; 59 were determined by
three independent anesthesiologists to have complications related to their
procedure in the lithotomy position. Of these 59 patients, 54 (1:3,675)
had persistent nerve injury while five patients (1:39,692) had compartment
syndromes. Although preliminary data do not identify mechanisms of injury,
many potential factors are possible. The authors are currently involved
in study of these 59 patients to determined the relative contribution of
various factors to nerve injury in the lithotomy position. The authors
further extrapolated their data to say that approximately 500 cases of
persistent nerve injury and 50 cases of compartment syndrome could be expected
in the U.S. each year from surgery in this position.

Can Simulation Accelerate the Learning of Basic Anesthesia
Skills?

Dr. M. Good and colleagues from the University of Florida
studied 26 residents just beginning their anesthesia training to determine
whether basic anesthesia skills taught in a simulator would accelerate
learning over the conventional lecture format. The residents were divided
into two groups and every day for two weeks the residents either attended
a lecture or trained in the simulator. There were 10 learning objectives
which included checking and operating the anesthesia machine and ventilator,
inducing general anesthesia, managing emergence and reversal of muscle
relaxants, and diagnosing and treating hypoxemia. The residents were evaluated
on the basis of a 'multiple choice test and by evaluations of their critical
performance by the faculty.

The pre-test and post-test did not show any significant
difference between the two groups. However, at Week 3 the change in the
clinical evaluation scores in the simulator group were significantly better
than those in the didactic group, but by Week 13 the two groups were equal
in their clinical evaluation scores. The authors concluded that teaching
basic anesthesia skills to new residents by use of an anesthesia simulator
can accelerate initial learning when compared with the traditional lecture
format.

Airway Management Issues

Several papers addressed airway management. Dr. R. From
and associates from the University of Iowa presented their evaluation of
'Sim I,' an interactive computerized learning program for airway management
developed for use in ACLS courses, in teaching medical students during
their third year anesthesia clerkship. Students received either the traditional
preclinical instruction on airway management from department faculty or
utilized Sim 1 without faculty interaction, and then their airway management
skills were evaluated when they got to the operating room. There was no
difference between the two groups in the degree of difficulty managing
airways by faculty evaluations or by their own evaluations, nor was the
students' level of satisfaction different. The investigators conclude that
the simulation program is no more effective than faculty instruction in
introduction to airway management, and are not utilizing this technology
in their clerkship program.

Two papers discussed the laryngeal mask airway (LMA).
Dr. J. Pennant and colleagues from the University of Texas, Southwestern,
evaluated this device as a method of initial airway management in patients
presenting with a possible cervical spine injury in a rigid collar. Placing
a rigid collar on normal volunteer patients prior to inducing anesthesia,
they compared the time to airway securement after induction of anesthesia
and paralysis utilizing the LMA or conventional laryngoscopy and intubation.
They found the LMA to allow faster and easier positive pressure ventilation.
They believe this device should be used when endotracheal intubation is
difficult or impossible in patients with possible cervical spine instability
and there is an immediate need for oxygenation and/or ventilation, even
though it does not reliably protect the airway from aspiration.

Dr. M. Maroof and associates from King Fahad National
Guard Hospital in Riyadh, Saudi Arabia, reported their modification to
the LMA which allows it to be used as a route for fiberoptic intubation
(FOI) with adult size endotracheal tubes. By removing the pliable grates
at the opening and slitting the device lengthwise along its entire length
including the cuff, they were able to insert the endotracheal tube through
it and then remove the LMA from around the tube. Without the lengthwise
slit, only a size 6 or smaller tube can be inserted over a fiberoptic scope
and the device has to remain taped in place until the endotracheal tube
is removed. This group tested the modified MLA as an aid to fiberoptic
intubation (FOI) by comparing time to successful intubation with and without
the device by experienced and inexperienced operators. Using the device
hastened intubation for both experienced and inexperienced and markedly
increased the success rate for those inexperienced in the technique of
FOI. From these two reports, it appears that the LMA can play a significant
role both in enhancing patient safety and teaching skills of fiberoptic
intubation.

Dr. K. Davis, Wilford Hall U.S.A.F. Hospital in San Antonio,
reported results of a survey to determine the prevalence of skills in fiberoptic
intubation (FOI) among anesthesiologists in the U.S. Teaching hospitals
have more fiberoptic intubating bronchoscopes, use them more often, and
feel they are more necessary than non-teaching hospitals. Academic faculty
and senior residents report a higher success rate and feel more capable
with FOI than do anesthesiologists in non-teaching hospitals. Dr. Davis
concludes that if an anesthesiologist is not able to acquire confidence
and skill in this technique during residency, it is unlikely that he or
she will be able to pick it up later.

Drs. S. Marsch and H. Keller report from the University
of Basel, Switzerland, that in that country FOI occurs three times more
often in teaching than non-teaching hospitals. Because electively performing
oral FOI after induction of anesthesia and paralysis is an excellent means
of acquiring this skill, they determined if there was a difference in patient
hemodynamic profile or postoperative morbidity using FOI as compared to
conventional laryngoscopy and intubation. Four third-year residents without
previous FOI experience were instructed in the technique with a video introduction
and extensive practice on a mannequin. They then performed FOI on 10 patients
and 10 conventional intubations, at which they were considered expert,
in random sequence. FOI took significantly longer than conventional intubation
for these novices (average 76 vs. 20 seconds), but hemodynamic data were
recorded on each patient and there was no difference in the profiles using
either intubation technique. There was also no difference in the incidence
of postoperative sore throat, dysphagia, or hoarseness with the two techniques.
The authors conclude that it does not compromise patient safety to learn
this technique by elective FOI after induction of anesthesia.

The Anterior Orifice

Confirming endotracheal intubation was addressed in two
papers. Drs. W. Gentry and C. Shanks from Northwestern University described
the Ford Maneuver using the Miller laryngoscope blade. In this maneuver
after the endotracheal tube is positioned (hopefully) in the trachea and
while the laryngoscope is still in place, a simple dorsal push of the tube
in the pharynx while exerting ventral pressure on the laryngoscope brings
the larynx into view so that the position of the tube passing between the
vocal cords can be directly viewed. They evaluated this maneuver's efficacy
in improving the Cormack and Lehane grade for larynx visualization after
intubation in 94 patients and found that it improved the grade in 71% of
patients. The Ford Maneuver had previously been evaluated only using the
MacIntosh blade.

Dr. R. Salem and associates from Illinois Masonic Medical
Center in Chicago described another simple means of testing for endotracheal
tube placement using a self inflating bulb from an asepto syringe. After
tube placement, the bulb is deflated and attached to the endotracheal tube.
If the tube is in the esophagus, the bulb will not reinflate. If the tube
is in the trachea, it will. This group tested the efficacy of the bulb
in identifying esophageal intubation in the presence of a nasogastric tube,
and found that it still led to no false positive conclusions. Dr. Salem
points out that there still might be false negatives, when the tube is
in the trachea but the bulb does not inflate. In cases where the tube is
linked, there is severe distal airway obstruction, or the diaphragm is
moving and creating negative airway pressure.

Various Complications

The pathogenesis of carbon monoxide production in anesthesia
circuits was investigated by Dr. R. Moon and colleagues from Duke University.
Postulating that fluroform in association with sodalime might be responsible
for the formation of CO, this group passed fluroform and the three inhalational
anesthetics through sodalime canisters at slow flows for 4-8 hours, then
the canisters were allowed to sit overnight. They were flushed with air
the following morning and the effluent gas analyzed for CO. The level of
CO did increase with the passage of inhaled agents and fluoroform through
sodalime, but not to the high levels occasionally reported in the literature.
The authors conclude that passage of fluorinated hydrocarbons through sodalime
does produce some CO in the circuit, especially after the canister sits
for a period of time, but that some other mechanism must also be involved.
They recommend using high fresh gas flows (>5 LPM) during anesthetic administration,
frequent changes of C02 absorbent canisters, and flushing the circuit before
using it after it has sat idle for a time.

Dr. A. Wong and his group from the Hospital for Sick Children
in Toronto investigated the cause of airway fires during tonsillectomy,
studying the contributions of an oxygen enriched atmosphere in the pharynx,
N20, and the presence of saline, epinephrine and bismuth on the tonsillar
packs. Measuring oxygen concentrations in the pharynx of children undergoing
tonsillectomy, they found that >21% oxygen occurred when uncuffed tubes
were used with controlled ventilation. Reproducing the environments they
found in the pharynx in bell jars, they tried to ignite cotton packs soaked
in saline, in epinephrine and in epinephrine and bismuth with diathermy.
The results showed that the presence of an enhanced oxygen atmosphere increases
combustibility of the packs no matter what they are soaked in. The dryer
the packs become, the more likely they are to ignite in an oxygen enhanced
environment. Finally, addition of bismuth to the packs significantly increases
combustibility. Efforts to prevent fires should include limiting leaks
around the endotracheal tube by using spontaneous ventilation and keeping
the packs wet.

Post op Airway

Evaluating, retaining, and treating the airway after extubation
is critical, especially if the post operative airway cannot be manipulated.
Drs. R. Cooper and S. Levytam from Toronto Hospital have developed a 65
cm catheter that can be placed through the endotracheal tube and is well-tolerated
when left in situ after extubation. This tube can be used for gas aspiration
and capnography, insufflation of 02, or jet ventilation. A spiral pattern
of side-holes at the distal end of the catheter allows jet ventilation
without catheter whip. The authors reported on 51 patients in whom it had
been used. Capnography and oxygenation were the two most common applications.
Jet ventilation was feasible, but barotrauma is still possible, especially
if the upper airway is obstructed.

Safety of procedures continues to be a major focus of
investigations both in the USA and abroad. The threat of a major vein perforation
even days after the placement of a CVP or multi-lumen catheter into a central
vein limits the usefulness of ft route of venous access, especially on
the general nursing floor. Drs. R. Blackshear and N. Gravenstein from the
University of Florida have examined five different catheter types regarding
their potential to perforate a membrane in an in vitro testing situation.
Catheters having rounded tips rather than beveled tips were much less likely
to perforate. Some of the catheters which perforated the in vitro membrane
easily had also been associated with in vivo perforations in the authors'
institution.

The safe use of a drug depends on careful attention to
known safety policies, one of which is the use of a test dose anytime a
potentially toxic dose of local anesthetic is injected. Dr. Y. Auroy et
al. from Clamart, France queried French anesthetists working in surgical
centers performing upper limb surgery under axillary block. They found
a higher than expected neurologic and cardiovascular toxicity rate. More
importantly, these experienced anesthetists were careful to aspirate and
inject the anesthetic slowly but rarely used a test dose, as was the routine
practice in performing epidurals. In another presentation, the safety of
epidural anesthesia by residents was analyzed by Dr. J. Naulty et al. from
George Washington University. Prospectively following 10 residents and
analyzing Ql forms and anesthesia records showed that unintended dural
punctures fell from 5% to 1% over three years and the need to replace an
epidural catheter because of inadequate anesthesia fell from 7% to 2%,
but the incidence of IV placement of the epidural catheter did not change
with time, remaining steady at 4% over the training period. This further
indicates the importance of a test dose to seek evidence of intravascular
placement of either needle or catheter.

Perioperative heat loss continues to be a topic of concern.
Dr. M. Barhorst et al. from the Mayo Clinic examined the temperature fall
in patients transported from the OR to the PACU (4.6 minutes average time).
Patients having continuous epidural anesthesia were colder at the end of
surgery (34.80 C by tympanic membrane probe) than were the patients given
general anesthesia (35.6o C). The epidural group temperature fell 0.3'
C while the general anesthesia group temperature fell 0.1 Co. Such differences
in core temperature seem small, but Dr. C. Sheffield et al. from the University
of California, San Francisco suggest that mild hypothermia of 30 C may
significantly alter resistance to infection. They anesthetized guinea pigs
for 6 hrs each, maintaining normal core temperature in 12 and 30 C low
in 12 others. Three doses of S. Aureus were inoculated intradermally after
two hours. Four days later, at the sites of the greatest inoculum, the
bacteria from the normothermic animals had decreased by 50% while the bacterial
count from the sites from the hypothermic animals had increased slightly.

Effectiveness of monitoring practices was also studied.
Knowing error patterns of commonly used and relied-upon monitors is a needed
feature of safety research. Dr. S. Barker et al. from the University of
California, Irvine, examined the responses of five different pulse oximeters
when placed deliberately half-on the finger or ear lobe but still recording
pulse accurately. The saturation readings were significantly in error but
not necessarily predictably so. The pulse oximeter should be in a position
that the anesthetist can frequently check it or reposition it if artifactual
readings occur. Dr. G. D'Honneur et al. from Creteil, France, examined
the precision and bias of two commonly used neuromuscular stimulation techniques
(train-of-four and double-burst) in evaluating neuromuscular recovery after
reversal of muscle relaxants. recording pulse accurately. The saturation
readings were significantly in error but not necessarily predictably so.
The pulse oximeter should be in a position that the anesthetist can frequently
check it or reposition it if artifactual readings occur. Dr. G. D'Honneur
et al. from Creteil, France, examined the precision and bias of two commonly
used neuromuscular stimulation techniques (train-of-four and double-burst)
in evaluating neuromuscular recovery after reversal of muscle relaxants.
200 patients who had had abdominal surgery were examined immediately after
arriving in the recovery room. Double-burst simulation was more precise
at recovery levels of TOF 40-70%, which is the important section of the
neuromuscular recovery curve in the recovery room. At either end of the
recovery spectrum, however, the two monitoring methods were equivalent.

Various Problems

An example of reluctance to follow directions was reported
by Dr. M. Roizen et al. in a multicenter report regarding the phase IV
post-marking study of propofol. The use of the drug was to start with induction
doses only and proceed to induction and maintenance by intermittent injection
and finally to TIVA by infusion. The study revealed that the drug was usually
used on fairly healthy patients (healthier than the usual surgical population).
However, occasional practitioners used it very quickly on older, sicker
patients with resulting hypotension and bradycardia, and a number of practitioners
began the third step of the phased use before finishing the first or second.
The analysis indicated that generally the bulk of anesthesiologists are
conservative in the early use of a new drug.

Conscious sedation by either midazolam or diazepam was
shown to be equally depressing to SpO2 during conscious sedation (Dr. J.
Gross, University of Connecticut), and direct feed-back from a capnograph
was shown to improve the efficiency of CPR as measured by higher C02 elimination
(Y. Lambert et al., Creteil, France)

Postoperative complications were addressed in two papers.
Dr. B. Grundy and associates from the University of Florida utilized telemetered
pulse oximetry on the surgical ward to determine if frequency and severity
of postoperative hypoxemia could be predicted by any patient or surgical
factors. Not surprisingly, obesity (>120% ideal body weight) correlated
most strongly with preoperative episodes of SaO2 <90%, but only weakly
predicted the severity of postoperative episodes. The greatest predictor
of postoperative desaturation episodes was major abdominal surgery, followed
distantly by inguinal herniorrhaphy, neurosurgery and superficial procedures
in that order. There was no correlation with ASA physical status, age or
smoking history. Desaturation episodes were more likely in patients who
had received general as contrasted with regional anesthesia. Episodes of
desaturation were not confined to the first few nights after surgery and
tended to be more severe the later they occurred. Supplemental oxygen therapy
did not prevent the episodes. Dr. Grundy and her group continue to utilize
this technology and linear analysis to perfect a system to predict who
should receive intervention to prevent episodes of postoperative hypoxemia,
which they speculate may account for at least part of the cognitive dysfunction
reported in some postoperative patients.

Dr. S. Kaseno and colleagues from Hokkaido University
In Sapporo, Japan, retrospectively compared a battery of liver function
tests in patients who received sevoflurane or isoflurane anesthesia during
a 12-month period beginning in September, 1990. They excluded all patients
who had preoperative alterations in hepatic or renal function, who received
a combined regional and general anesthetic, who received blood products
perioperatively, or who had cardiovascular, thoracic or abdominal surgery.
There were about 100 patients who received each anesthetic and did not
differ in any characteristics. Patients receiving isoflurane showed minimal
effects on every liver function test. Patients receiving sevoflurane exhibited
significantly higher values for AST, ALT, gammaGTP and LAP than did those
receiving isoflurane from 7 to 28 days postoperatively. These elevations
correlated with the duration of exposure to the agent. LAP and ALT values
were outside the normal range at 14 days for the group receiving sevoflurane,
but there was no evidence of clinical liver dysfunction. Bilirubin levels
did not change in either group. The impact of this and similar studies
on the use of Sevoflurane in this country remains to be seen.

Open Packages Safe

In the arena of cost containment, we were told by a group
from the University of South Carolina led by senior medical student M.W.
Moore that we can use endotracheal tubes up to at least five days after
we open the package and test the cuff, if we don't take the tubes out of
their packages and get them dirty. These investigators cultured tubes from
opened packages stored in carts of their least and most busy operating
rooms at 24, 48 and 120 hours by swabbing them on a blood-agar plate and
then immersing them in thioglycolate broth. Neither culture method showed
any growth for any tube. The investigators speculate that they can save
their department at least $21,000 per year by not discarding all tubes
in opened packages at the end of a day, so long as they are careful to
keep them clean.

Provider Safety

There were several posters summarizing studies about the
safety of the anesthesiologist. Dr. A. Tait of the University of Michigan
mailed a questionnaire to 70 anesthesiologists at four hospitals asking
about their compliance with CDC guidelines for the prevention of HBV and
HIV transmission to these practitioners. Forty-seven percent reported having
suffered 1 to 2 needlesticks during the previous year. Sixty-three percent
admitted to frequently recapping needles; only 6% said they never did so.
The figures for those who wore gloves are also remarkable e.g. only 56%
wore them even when contact with the patient's blood was a possibility.
Nevertheless 50% reported that they had altered their habits since the
AIDS scare. The author reminds us it is estimated that 40% of all occupational
HIV transmission could have been avoided by proper disposal of needles
and by following CDC guidelines.

Dr. A. Rosenberg and colleagues from New York University
mailed a questionnaire to a random 10% sample of ASA members and got answers
from 1,367 anesthesiologists. They also noted considerable improvement
in self protective habits. There was a decrease in reuse of syringes containing
drugs such as vasopressors which can be available for several consecutive
patients. Residents were better than attendings at wearing gloves when
starting IV or arterial lines. During the period of the study, 8.5% of
the residents and 3.7% of the attendings sustained needle-sticks while
taking care of patients known to be HIV positive.

Drs. W. Merritt and A. Zuckerberg at Johns Hopkins Hospital
studied contamination of the anesthetic record. At first blush one would
imagine that this refers to such heinous activity as 'smoothing' of notations
of vital signs on the anesthetic record. Their study must be taken literally;
for on their poster they displayed an anesthetic record with splashes of
dried blood. They found that 51 % of the records of anesthetics for CABC
and abdominal aneurysm operations were contaminated. Even 15% of those
for laparoscopic cholecystectomy were also affected. There war,-' some
correlation to the frequency of lab specimens 'I drawn from the patients
and number of units of blood administered. They could not always find a
mechanism but suggest that increased vigilance, frequent glove changes
and hand washing, innovative blood sampling techniques and the use of automated
record keeping might diminish this potential hazard to the anesthesiologist.

Dr. M. Williams et al. from the University of Colorado
conducted a pilot study to see if physician addicts had any difficulty
returning to abstinence after they had had operations which required them
to receive sedatives or narcotics. They got their information from the
directors of five state recovery programs and received 51 completed replies.
Approximately half were ex-alcoholics and the rest were former drug addicts.
The mean preoperative period of abstinence was four years. Close to 30%
of the former drug addicts developed cravings for their former drug of
choice and experienced emotional lability and the need for supportive care
whereas only 7.4% of alcoholics relapsed. The authors conclude that even
years after recovery addicts may be at risk for relapse if exposed to sedatives
or narcotics given for surgical indications.

Lastly, Dr. J. Zacny and associates wondered if propofol
had the potential to become a drug of abuse. They studied the subjective
effects of subanesthetic dose infusions in 10 volunteers and performed
a double blind randomized cross-over study using the vehicle for propofol,
Intralipid, as a control. Five of the subjects liked the real thing whereas
most of the group on receiving the vehicle were neutral about its effects.
The authors conclude from this preliminary study that propofol may have
some potential for abuse.

In all, the diverse and extensive spectrum of safety-related
presentations at this year's meeting illustrates yet again that patient
safety issues have become a very significant component of anesthesia practice.

Dr. Aukburg, University of Pennsylvania, is a member of
the Newsletter Editorial Board. Dr. Ehrenwerth, Yale University, is a member
of the Board of Directors of the APSF and a member of the Newsletter Editorial
Board. Dr. Gild, University of Washington, chaired one of the ASA scientific
sessions, as did Dr. Polk, who is from the University of Chicago; Dr. McGee,
Northwestern University is from Evanston (IL) Hospital, and Dr. Zeitlin
of the Brigham and Women's Hospital and Harvard in Boston is a Newsletter
Associate Editor.

Infection Control in the Practice of Anesthesia, Videotape
Number IS in the series cosponsored by the ASA, considers the prevention
of infection in patients undergoing anesthesia, strategies for reducing
occupational transmission of infection to practitioners, and the necessity
for anesthetists to incorporate universal precautions in infection control.
It addresses the procedural considerations for anesthesia concerning nosocomial
infection, blood borne pathogens, airborne pathogens, contact pathogens
and the awareness of HIV infection. David Cheney, M.D., an anesthesiologist,
describes the danger to the anesthesia provider in telling his own experience
with an accidental needlestick that led to his becoming HIV Positive.

The videotape was made possible by an educational grant
from Burroughs Wellcome Company and will be available for distribution
by them in late Fall. Arnold I. Berry, M.D., was producer and Mark P. Fritz,
M.D., and Samuel C. Hughes, M.D., associate producers. Filming took place
at Emory University Hospital, Atlanta, GA. GWF Associates, Holmdel, New
Jersey, collaborated on scripting, technical development, and filming.

Central Venous Catheter Complications

Central Venous Catheter Complications, Videotape Number
17 comprising a three-part series, was developed to inform clinicians about
the many possible complications associated with Central Venous Catheters
(CVCs).

The first parts are directed toward individuals who place
CVCs and have a need to review the anatomy, pathology and radiology. Later,
the tape discusses CVC-related infection and peripherally implanted central
lines, as well as home-care aspects of CVC placement and maintenance. The
tape was funded and prepared under the direction of the Food and Drug Administration
(FDA), several specialty societies and catheter manufacturers. Special
recognition should go to the Central Venous Catheter Working Group for
their efforts in the planning, preparation and completion of the project.
Walter L. Scott, Ph.D., was the Project Director for the FDA and Anesthesiologist
David M. Paulus, M.D., University of Florida College of Medicine, Gainesville,
the chief Technical Consultant. The APSF acted as the financial holding
organization. Segments of the three-part series were taped on location
at: New England Deaconess Hospital, Boston, MA; Franklin Square Hospital
Center, Baltimore, MD; University of Florida, Shands Hospital, Gainesville,
FL; National Institutes of Health, Bethesda, MD; Uniformed Services University
of the Health Sciences, Bethesda, MD; Food and Drug Administration, Rockville,
MD.

There will be several modes of distribution, including
7,000 copies to -all hospital administrators in the United States. #or
American anesthesia practitioners, Burroughs Wellcome Company will begin
distribution to 'anesthesia departments in January 1993 in the usual manner.
In addition, copies are available to other parties from the National Audiovisual
Center for approximately $90.00 a set.

A document entitled 'Critical knowledge and technical
competence required of physicians involved in interventional pain management"
has been developed by a task force organized by the Dannemiller Memorial
Educational Foundation, an organizer of anesthesiology continuing medical
education (CME) programs since its inception in 1984.

These guidelines arose from a need perceived by the Dannemiller
group and specifically its President, Alon P. Winnie, M.D. of Chicago,
due to the absence of any widely accepted standards of care concerning
interventional pain management and, especially, implantable pain control
devices.

The impact of the ASA Closed Claims Project was examined
at the ASA Annual Meeting on October 20 in a panel session of the Committee
on Professional Liability with the Director of the ASA Closed Claims Project.

Panel participants included Jeffrey B. Cooper, Ph.D. (Director
of Anesthesia Technology at Massachusetts General Hospital), Ellison C.
Pierce, Jr., M.D. (President of the Anesthesia Patient Safety Foundation),
Mr. Mark Wood (Director of Risk Management Services at St. Paul Fire and
Marine Insurance Company), and Robert A. Caplan, M.D. (Chairman of the
ASA Committee on Patient Safety and Risk Management and Co-Director of
the ASA Closed Claims Project). Dr. Fred Cheney, the other Co-Director
of the ASA Closed Claims Project, reviewed the history and present status
of the Closed Claims Project. The feasibility of closed claims analysis
was first demonstrated by Dr. Richard Ward in the mid-1980s. Since that
time, the Closed Claims Project has grown vigorously.

At present, the project database contains nearly 3,000
claims, collected from the closed files of approximately 30 U.S. insurance
carriers. The primary work force of the project is a dedicated team of
practicing anesthesiologists who make a voluntary donation of time and
expertise in order to review and analyze closed claims. Dr. Cooper provided
a critical appraisal of the project methods, emphasizing the merits of
sentinel event analysis and its successful application in this area of
research. He also reviewed the limitations imposed by the retrospective
nature of Closed Claims data, and the potential for bias and distortion
by original participants and later reviewers. Dr. Pierce described the
positive impact of the Closed Claim. Project on patient safety, highlighting
the pivotal role that claims data have played in the formulation of monitoring
standards. Mr. Wood used the claims experience of the St. Paul Company
to illustrate the linkage between improved intraoperative monitoring and
the reduction in hypoxic injuries. Dr. Caplan presented a brief survey
of the scientific study of peer review, another area of focus for the Closed
Claims Project. Preliminary research indicates that anesthesiologists show
significant agreement on basic issues of peer review, but the strength
of agreement is modest and physician judgments are strongly biased by outcome.
Explicit tools for case review may improve the validity and reliability
of peer review. Dr. Cheney concluded the panel session with a glimpse into
the future. He predicted that claims for inadequate ventilation, esophageal
intubation, and injuries arising from difficult intubation would all show
a considerable decline, largely as the result of pulse oximetry, end-tidal
capnography, and improved strategies for difficult airway management. He
also predicted that peripheral nerve injuries would persist, unless research
efforts yield a better understanding of the basic anesthetic injuries.

Dr. Caplan, Mason Clinic, Seattle, WA, chairman the ASA
Committee on Patient Safety and risk Management, is on the Executive Committee
of the APSF.

The year 1992 was another good one for the Foundation.
An important continuing endeavor was funding for research grants in anesthesia
safety, with some $175,000 given to investigators at three institutions.
The awards were for examination of safety and risk factors associated with
postoperative regional analgesia in pediatric patients; study of the effects
of long work hours on the ability of anesthesia and surgical providers
to monitor multiple sources of information, to learn and to retain information;
and application of the technique of probabilistic risk assessment to develop
a quantitative risk analysis model for anesthesia and to assess the effects
of organizational factors in the risk of accidents.

The Newsletter continues to be the major organ worldwide
for dissemination of issues of importance in anesthesia patient safety.
With more than 50,000 copies distributed quarterly, it has been cited as
the largest-circulation anesthesia publication in the world. In the last
four issues, among many items, it reviewed patient safety activities at
the ASA meeting, summarized significant articles from the literature, examined
specific problems in patient safety, discussed the role that European 'work
stations' may have in U.S. anesthesia equipment development, reported on
one of the simulator systems that had been partially funded by the Foundation,
analyzed whether anesthesiologists and nurse anesthetists have a problem
with equipment competency, and described the recent International Standards
for Safe Practice, endorsed by the World Federation of Societies of Anesthesiologists.

Simulators Supported

The APSF continued its strong financial support for development
of anesthesia simulators, primarily at Stanford and the University of Florida.
In addition to examining the operating room environment, interest will
also be directed toward that of the post-anesthetic care unit. In an effort
to reduce costs associated with administration, the Foundation has opened
an Executive Office in Pittsburgh to be run by the new APSF Executive Director,
E. S. Siker, M.D. This undertaking will consolidate nearly all of the Foundation's
activities in one center.

The APSF also provided partial funding for the June meeting
of the International Committee on Prevention of Anesthesia Morbidity and
Mortality as well as for a 1993 meeting on Human Performance in Anesthesia,
co-sponsored by APSF and the Society for Technology in Anesthesia. The
Foundation has begun an examination of the possibility of developing a
nationwide confidential reporting system for collecting safety-related
anesthesia events and established a CA-3 investigator award. A major event
during the year was the convening of a Board of Directors Retreat in New
Orleans preceding the ASA annual meeting. Some 45 members of the APSF Board
and Committees attended the all day symposium.

Lastly, all of us on the APSF Executive Committee and
Board appreciate the significant interest in the Foundation seen on the
part of many anesthesiologists worldwide. As noted last year, other specialty
societies and the American Medical Association continue to laud the anesthesia
community for its leadership role in patient safety activities.

Safety-related technology and ideas certainly were featured
in the technical and scientific exhibits at the American Society of Anesthesiologists
Annual Meeting in New Orleans in October, but there were comparatively
few genuinely new ideas. Packaging and presentation of existing technology
continues to vary in a multiplicity of permutations and combinations.

In the technical exhibits, patient temperature seemed
to surpass oximetry as the most common focus. There were at least 12 major
displays centering on the issue of unintended patient hypothermia in the
operating room. Many varieties of the already existing mechanisms to add
and/or preserve heat in an anesthetized patient (from above, below, or
via the gases and fluids) were presented. In response to questioning on
the reason for the emphasis on this topic, representatives from various
companies with these displays replied that anesthesia practitioners seemed
very concerned with their patients who accidentally become cold during
surgery.

Various nontraditional monitors were highly touted. There
was an esophageal probe that allows ECG recording from directly behind
the heart (and another that can be used for cardiac pacing). The cerebral
oximeter with an infrared sensor applied to the forehead that is claimed
to read regional brain tissue oxygen saturation through the skull bone
was displayed again. Advertised as a new technology, a noninvasive cardiac
output monitor was shown. It involves two electrodes on the left lateral
chest wall and also two at the root of the neck. A low amplitude current
is generated and the electrical conductivity of the blood causes changes
in intrathoracic incidence that can be detected by the monitor which then
does 'time-frequency signal processing' to make projected calculations
about the mechanical function of the heart. Among the many parameters displayed
on the monitor are CO, stroke volume, ejection fraction, end-diastolic
volume, and SVR.

A new smart technology for vessel finding was displayed.
An ultrasound device that detected differences, for example, between the
internal jugular vein and the carotid artery can be attached to a needle
and apparently help guide needles and catheters into the central venous
circulation.

Real-time blood gas measurement technologies were more
numerous this year. Four that involve intra-arterial sensors and two that
make measurements outside the body were displayed. AU these manufacturers
stated with no hesitation that they have finally solved the fibrin-deposition
problems that have prevented this type of technology from succeeding in
the past.

Automated anesthesia record keeping devices and OR information
management systems were prominent with three of each offering new upgrades
of previously available technology.

In a simple, but important, area, there were several devices
shown that are specifically intended to shield and protect anesthetized
patients' ulnar nerves from potential compression damage and resulting
neuropathy.

New versions of labels for syringes that are intended
to help avoid wrong-medication errors were prominently displayed.

A pneumatic device to allow 'pumping up" for left uterine
Wt to avoid aorto-caval compression was offered as a new easy way to implement
this important safety maneuver.

While not specifically offered as new safety devices,
laryngeal mask airways arrived in full force in the US at this meeting.
How these impact practice and any safety implications, positive or negative,
remains to be seen as they are put into clinical practice and studied.

In the scientific exhibits, there was a demonstration
of a proposed simple way to detect esophageal intubation. A compressed
large suction bulb is attached to the connector of a newly placed endotracheal
tube. If the deflated bulb immediately reinflates, the tube is in the trachea.
If not, it is either in the esophagus or obstructed. The presenter stated
that this had been used in more than 1,500 anesthetics and it had correctly
diagnosed one unrecognized esophageal intubation.

Bulb for Trachea

Potentially a harbinger of the future, another scientific
exhibit featured a so-called 'heads-up" display of monitoring information
on a screen attached to the surgical drapes at the level of the patient's
head. This computer-based projection system allows the monitoring displays
to be seen by the anesthetist in the same field of vision as the patient.
Such technology may eventually lead to helmet or even eye-glass like devices
(similar to those used by fighter pilots) the anesthetist will wear and
then have all the monitoring displays always directly in view.

Dr. Eichhorn of the University of Mississippi is Editor
of the APSF Newsletter.

Small but important modifications to two of the formal
sets of ASA standards of practice were made by the House of Delegates at
the October ASA Annual Meeting.

The Standards for Basic Intraoperative Monitoring were
strengthened by the addition of the word 'strongly' to the encouragement
of the use of continuous capnography. Item 2 of Standard 11, Ventilation,
now reads: "When an endotracheal tube is inserted, its correct positioning
in the trachea must be verified by clinical assessment and by identification
of carbon dioxide in the expired gas. End-tidal C02 analysis, in use from
the time of endotracheal tube placement, is strongly encouraged."

Likewise, the Standards for Postanesthesia Care were supplemented
by a new reference to the monitoring of temperature in the immediate postoperative
period. The relevant section now reads: "...particular attention should
be given to monitoring oxygenation, ventilation, circulation and temperature."

Both changes were recommended by the ASA Committee on
Standards of Care and were adopted by the House without opposition. In
response to the directive from the 1991 House of Delegates, the Committee
did evaluate the suggestion that continuous capnography be made a formal
standard. The Committee felt that to do so would require a number of caveats
and exceptions, particularly regarding pediatric patients, and that this,
coupled with the features already in the existing standard as quoted above,
argued in favor of not adopting the suggestion.

The APSF Committee on Scientific Evaluation has once again
awarded research grants for patient safety-related studies. Four of 15
grant applications were approved for funding of a total of $155,658. These
studies represent different aspects of patient safety: study of a factor
affecting human performance, validation of a new measurement for studying
human performance, mechanisms of a specific event and examination of a
new monitoring concept.

Sleepiness and Fatigue in Anesthesiologists in Training

Dr. Steven Howard will lead a unique collaboration between
researchers at the Stanford University Department of Anesthesiology and
Stanford Sleep Disorders Center to evaluate acute and chronic fatigue in
anesthesiology residents.

Dr. Howard

A variety of experimental methods will be used to (1)
quantify the level of sleepiness during .rested' and sleep-deprived states;
(2) examine whether or not brief mental lapses (microsleeps) are occurring
in residents while on duty; (3) examine sleep, work and recreational habits
of anesthesia residents; (4) evaluate a computer-based instrument that
measures performance on medically relevant tasks. The latter instrument
is modified from the .synthetic work environment' program (SYNWORK) used
for examining performance in the US Army.

This study is expected to produce new information about
the physiological sleepiness of anesthesia residents, determine for the
first time if microsleeps occur and validate a new test of performance.
The investigators believe that their techniques and experimental design
will avoid flaws in previous studies that hampered objective interpretation
of the results.

A Search for Mechanisms of Intraoperative Carbon Monoxide
Poisoning

Dr. Moon

Dr. Richard Moon and colleagues at the Duke University
Medical Center will expand their efforts to identify the cause(s) of suspected
CO poisoning that has been identified intraoperatively in some cases. Interaction
with carbon dioxide absorbent in breathing systems is the primary suspect
mechanism. To test as many as six hypotheses, a battery of experiments
will be performed using several analytical techniques employing various
radiolabelled species. Depending upon the results, two prevention strategies
may be examined.

Identifying a Cerebral Ischemic Threshold

Dr. Levy

A measure of the adequacy of brain oxygen levels is much
sought after, but elusive. Transcranial near-infrared spectrometry has
been examined as a possible technique. This study, to be undertaken by
Dr. Warren Levy at the University of Pennsylvania, has the primary objective
of determining the saturation of hemoglobin in the cerebral vasculature
that is associated with electroencephalographic evidence of cerebral ischemia.
Continuous phase-modulated near-infrared spectrophotometric measurement
of changes in hemoglobin saturation and EEG recordings will be performed
in patients undergoing implantation of an internal cardioverting defibrillator,
a procedure that frequently produces EEG evidence of cerebral ischemia.
It is expected that definition of the 'ischemic threshold" could make measurement
of cerebral oxygenation possible in situations where alternative monitoring
is not successful or practical.

Creating a Measure of Intraoperative Vigilance

Dr. Loeb

Despite the great interest in the concept of vigilance
in anesthesia, the few studies of the subject have lacked an objective
measure of intraoperative monitoring performance. Dr. Robert Loeb of the
University of California Davis Medical Center will lead a study to validate
a measure of intraoperative vigilance during the conduct of a routine case.
The artificial talk (an extra display mounted on a non invasive blood pressure
monitor) was tested in a pilot study (Loeb RG:A measure of intraoperative
attention to monitor displays, Anesth Analg, 1993, in press) and its validity
will now be examined versus a real task in which the loss of real patient
data (a blanked non invasive blood pressure display) must be recognized.
The question to be answered is if performance in the simulated vigilance
task differs from performance of the real vigilance task. If the simulated
task proves valid, Dr. Loeb plans to use it in other studies of factors
affecting intraoperative vigilance.

Those considering applying for a grant to begin in January
1994 should contact the APSF Executive Office for instructions for submission.
The maximum award will continue to be $50,000.

Dr. Cooper of the Massachusetts General Hospital, Boston,
is the Chairman of the APSF Committee on Scientific Evaluation and a member
of the APSF Executive Committee.

Revisions to the official, government-sponsored anesthesia
equipment checkout recommendations have been proposed and comments from
all members of the anesthesia practice community are sought.

In 1987, the United States Food and Drug Administration
(FDA) published Anesthesia Apparatus Checkout Recommendations, a checkout
procedure by which anesthesiologists and anesthetists can determine whether
an anesthesia gas machine is functioning properly and is ready for patient
use. Studies of the checkout protocol have revealed that it is neither
well understood nor used correctly by a majority of anesthesia practitioners.
When challenged to check anesthesia machines intentionally configured with
a variety of malfunctioning components, clinicians detected only 28.5%
of the faults. (1) In March, 1991, the FDA reviewed the development of
the checkout procedure and studies of its effectiveness at a meeting convened
by the American Society of Anesthesiologists' (ASA) Committee on Equipment
and Facilities. Invited participants included representatives of the ASA,
the ASA Committee on Equipment and Facilities, the Anesthesia Patient Safety
Foundation (APSF), the American Association of Nurse Anesthetists (AANA),
anesthesia machine manufacturers, and anesthesia equipment experts.

The result of that meeting and other subsequent work has
led to a 1992 draft revision of the Anesthesia Apparatus Checkout Recommendations.
Availability of this document was announced in the October 6, 1992, Federal
Register. The FDA has requested that written comments on the draft document
be sent by February 16, 1993 to the Dockets Management Branch (HFA-305),
Food and Drug Administration, Room 1-23,12420 Parklawn Drive, Rockville,
MD 20857. Comments should be identified with the docket number 86B-0058.
The Federal Register article announcing availability of revised document
merely describes the modifications that transformed the original 1987 Checkout
Recommendations into the currently proposed 1992 draft. The Federal Register
article does not include the entire document, which makes it impossible
to provide meaningful comments. Thus, the complete draft of the 1992 Anesthesia
Apparatus Checkout Recommendations is included in this issue of the APSF
Newsletter so that anesthesia practitioners can review it. As recommended
in a recent APSF Committee on Technology Position Paper, narrative comments
describing the rationale for each specific step and for the revision process
in general are included.

Rationale

Many clinicians believe that existing protocols for anesthesia
machine checkouts are too long and too complex. Those who revised the recommendations
agreed that the average clinician should be able to check an anesthesia
machine in 5 minutes or less. This is not possible with the 1987 Checkout
Recommendations or with check procedures published by anesthesia machine
manufacturers in the manuals for their anesthesia machines.

Contemporary anesthesia gas delivery machines are durable
and dependable. They fail infrequently. They are armed with alarms and
safety devices, which, coupled with the array of monitoring instruments
used in contemporary anesthesia practice, make failure of most components
in the anesthesia machine easily detectable before the safety of the anesthetized
patient is jeopardized.

Safe Fail Safe?

For example, many checkout protocols include daily testing
of the oxygen pressure failure safety mechanism (fail-safe), a durable
device that arrests the flow of other gases when the oxygen supply pressure
(pipeline or cylinder) decreases below a preset threshold, which prevents
continued flow of a hypoxic gas mixture. Does the isolated failure of the
fail-safe mechanism put the patient at immediate risk? I do not think so.
Failure of the fail-safe mechanism does not affect the normal function
of the anesthesia machine as long as the oxygen supply pressure is adequate.
Even if the fail-safe mechanism malfunctions AND the oxygen supply pressure
is simultaneous lost, the anesthesia provider is warned by several if not
all of the following: (1) low oxygen-supply pressure alarm in anesthesia
machine, (2) low oxygen-supply pressure alarm in mechanical ventilator,
(3) failure of the mechanical ventilator to cycle properly, (4) report
of low oxygen concentration in the breathing circuit by the oxygen analyzer
(and an alarm if it is set), and (5) report of decreased oxyhemoglobin
saturation by the pulse oximeter. Even in a 'worst case" scenario, the
anesthesiologist or anesthetist is warned of the developing hypoxic gas
mixture, as first the inspired oxygen concentration and then the oxyhemoglobin
saturation begin to decrease. This combination (a hypoxic gas mixture and
oxyhemoglobin desaturation) indicates that the patient should be disconnected
from the anesthesia machine.

In contrast to the seemingly complex fail-safe mechanism,
is the seemingly innocuous and simple scavenging system. Yet certain failures
of the scavenging system can cause pulmonary barotrauma in just a few breaths!
For example, anesthesia personnel have used adhesive tape to incorrectly
mate a standard 22-mm breathing circuit hose to the 15-mm scavenging port.
If the adhesive tape slips into the hose and obstructs its lumen, a closed
circuit is created when mechanical ventilation is instituted. Gas flowing
into the breathing system cannot escape, and airway pressures (both inspiratory
and expiratory) quickly rise and may exceed 40 cm H20. (This scenario is
demonstrated in the ASA/APSF Patient Safety Video 412.)

The 1992 FDA Anesthesia Apparatus Checkout Recommendations
have retained or added checks of machine components that fail more frequently
than other components (for example, breathing system), and those components
that directly and quickly injure the patient when they fail (for example,
scavenging system). Components that fail infrequently and that do not put
the patient in immediate danger when they do fail are not included in the
1992 Checkout Recommendations but should be checked as part of routine
periodic maintenance. In the paragraphs that follow, the specific rationale
for each checkout step is discussed.

Introductory Paragraph

The introductory paragraph clearly states that the checkout
procedure is valid only for anesthesia machines with an ascending ('upright')
bellows " of mechanical ventilator and a specific array of monitoring instruments.
This configuration forms a web of safety systems that warn the clinician
and protect the patient from injury in the event of an isolated component
failure.

Clinicians using anesthesia machines that do not conform
to this configuration or to current manufacturing and monitoring guidelines
must critically analyze the specific failures that might go unrecognized
and adapt the checkout procedure as indicated. For example, the 1992 Checkout
Recommendations specify that a capnograph should be in use. The 1987 Checkout
Recommendations stipulated that clinicians verify that the unidirectional
valves are-competent by inhaling and exhaling into isolated limbs of the
breathing system. While this is a sensitive test for detecting valve malfunction,
many clinicians prefer not to share the breathing system with their patients.
Incompetent unidirectional valves are readily detected with a capnograph,
an instrument that reports minimum ('inspired') and maximum ('expired'
or 'endtidal') concentrations of carbon dioxide and also traces a capnogram,
a plot of the airway carbon dioxide concentration as a function of time.
Characteristic changes in the shape of the capnogram accompany both incompetent
inspiratory and expiratory valves. An incompetent inspiratory valve, however,
may not be detected with a capnometer, an instrument that only reports
the minimum and maximum concentrations of carbon dioxide during each respiratory
cycle.

Steps Removed from the Checkout Recommendations:

Nitrous Oxide and Air Cylinder Gas Supply

Nitrous oxide and air are not life-sustaining gases. While
the undetected loss of nitrous oxide may result in 'light' anesthesia and
the potential for awareness and recall, once detected, intravenous or other
inhaled anesthetic agents can be used to re-establish the appropriate anesthetic
depth. Thus, while it may be reassuring to have reserve cylinders of nitrous
oxide and air attached to the anesthesia machine, daily checks of their
pressure is not thought to enhance safety.

Low Oxygen-Supply Pressure Alum

Contemporary anesthesia machines alarm when the oxygen
supply pressure (from pipeline or cylinder) falls below a preset threshold,
usually 25 to 30 psig. This alarm sounds each time the anesthesia machine
is turned on and off, which pressurizes and depressurizes the alarm mechanism.
The 1992 Checkout Recommendations do not include daily checks of this alarm
mechanism. Isolated failure of the low oxygen-supply pressure alarm will
not injure a patient. Failure of the alarm coupled with loss of oxygen
supply pressure should similarly not injure the patient because the oxygen-pressure
failure safety mechanism (fail-safe) will arrest the flow of other gases
to prevent the patient from inspiring a hypoxic gas mixture. Mechanical
ventilators that are powered by oxygen pressure should independently alarm
when oxygen supply pressure is lost. Should this alarm in the ventilator
also fail, instruments that monitor ventilation of the patient's lungs,
specifically the capnograph and spirometer, will immediately warn the clinician
because loss of oxygen supply pressure to a mechanical ventilator results
in apnea.

Oxygen Pressure-Failure Safety (fail-safe) Mechanism

This device arrests the flow of all gases except oxygen
whenever the oxygen supply pressure falls below a preset threshold, typically
30 psig. This prevents the hypoxic gas mixture that would result from the
continued flow of, for example, nitrous oxide without oxygen. As with the
low oxygen supply pressure alarm, daily testing of the oxygen pressure-failure
safety mechanism is not included in the 1992 Checkout Recommendations because
its failure does not directly injure the patient, and multiple simultaneous
failures are required before the patient is at risk of injury. Even if
the oxygen pressure-failure safety mechanism failed along with the simultaneous
loss of oxygen supply pressure during anesthesia with nitrous oxide, the
low oxygen-supply pressure alarm will indicate loss of oxygen supply pressure.
If this alarm failed, as noted in the previous section, the oxygen analyzer
and the pulse oximeter will warn the clinician of the hypoxic gas mixture,
regardless of its cause.

Steps Retained in or Added to the 1992 Checkout Recommendations:

1. Verify Backup Ventilation Equipment is Available &
Functioning

Though rare, certain malfunctions (for example, contaminated
oxygen supply, loss of oxygen supply pressure, total obstruction of the
breathing system) render the anesthesia machine inoperable. When this happens,
a patient must be quickly disconnected from the anesthesia machine and
the patient's lungs ventilated by using backup ventilation equipment. Therefore,
the 1992 Checkout Recommendations begin with a check of the backup ventilation
equipment. Example systems include self-inflating resuscitation bags, or
Mapleson-type circuits with separate oxygen cylinder.

2. Check Oxygen Cylinder Supply

The length of time an anesthesia machine can operate on
the reserve oxygen cylinder depends on the volume of compressed oxygen
in the cylinder and on the rate of use. The volume of oxygen in the reserve
cylinder is directly proportional to its pressure, a W oxygen cylinder
having 625 liters and a pressure of approximately 2200 psi. The 1992 Checkout
Recommendations suggest that at least one reserve oxygen cylinder be at
least half full, in other words, have a pressure of at least 1000 psi,
which will enable the anesthesia machine to function for 10 minutes to
over an hour, depending on rate of use. Because many anesthesia ventilators
are powered totally or in part by oxygen, a low flow of oxygen and either
spontaneous ventilation or manual ("bag') ventilation will prolong the
time the anesthesia machine can operate with a reserve oxygen cylinder.

3. Check Central Pipeline Supplies

Normal operating pressure for pipeline gases is 45 to
55 psi. A lower pressure suggests that a pipeline hose is not properly
connected, that the hose is kinked, that the hose or connector is defective,
or that the pipeline system itself has a problem. A higher than normal
pressure also suggests that the primary problem is the pipeline system,
not the anesthesia machine.

4. Check Initial Status of Low Pressure System

This check is a preparatory step in setting certain controls
(that is, flow control valves, vaporizer concentration knob) and sensors
(that is, sensor for oxygen analyzer) for subsequent steps in the checkout
procedure. The vaporizers are checked and, if necessary, filled at this
point as well.

5. Perform Leak Check of Machine Low Pressure System

The low pressure system of the anesthesia machine comprises
all components between the flow control valves and the common gas outlet
and includes the flow meter tubes, vaporizers, connecting manifolds, and,
if present, a common gas outlet check valve. The concentration of volatile
anesthetic in the fresh gas mixture may be significantly decreased with
small leaks, for example 100 ml/min, in the low pressure system of the
anesthesia machine, which may result in consciousness and recall. In certain
situations, leaks in the low pressure system may also lead to the patient's
inspiring a hypoxic gas mixture, even though a nonhypoxic fresh gas flow
ratio has been set.

A variety of check procedures have been proposed for detecting
leaks in the low pressure system of the anesthesia machine. A positive
pressure leak check (occluding the Y-piece of the breathing circuit, pressurizing
it to 20 cm H20, and observing the canister pressure gauge for loss of
pressure) will not detect a leak in an anesthesia machine with a common
outlet check valve, because positive pressure in the breathing system cannot
be transmitted back into the low pressure system. The negative pressure
leak check (attach suction bulb to common gas outlet, squeeze to develop
negative pressure, and observe to see if bulb remains collapsed) detects
leaks in the low pressure system on all makes and models of anesthesia
machines and is sensitive enough to detect the small leaks (100 ml/min)
that can disrupt the proper function of the low pressure system. When done
correctly, both positive and negative pressure leak checks require the
use of a bulb attachment to the anesthesia machine. Accordingly, so that
a single, highly sensitive check procedure could be recommended for all
anesthesia machines, the 1992 Checkout Recommendations suggest using the
negative pressure leak check for the low

6. Turn On Machine Master Switch

This enables subsequent checks to be performed.

7. Test Flowmeters

This step verifies that gas is flowing into the anesthesia
machine; that the flow control valves and flow meters are functioning;
and that the 'hypoxic guard' mechanism either prevents the clinician from
setting a hypoxic oxygen-nitrous oxide fresh gas flow ratio or alarms when
such a flow ratio is set.

8. Calibrate 02 Monitor

A contaminated oxygen supply (for example, oxygen-nitrous
oxide pipeline cross, non-oxygen gas in oxygen pipeline or cylinder) can
only be diagnosed by a functioning and calibrated oxygen analyzer. Other
malfunctions within the anesthesia machine, as well as a very low rate
of fresh gas flow, may also lead to hypoxic gas. Therefore, the oxygen
analyzer should be calibrated at 21% and checked at high oxygen concentrations
daily. (Do not recalibrate the analyzer at a high oxygen concentration
because greater accuracy is needed at low concentrations.)

9. Check Initial Status of Breathing System This is a
preparatory step in which the clinician assembles and visually checks the
breathing system, carbon dioxide absorbent, and any other breathing circuit
accessories (for example, PEEP valve, humidifier system) required for the
next case. It is important to add breathing circuit accessories before
completing the checkout procedure. If the accessory has a fault (for example,
a leak in the humidifier circuit), it will not be detected if attached
to the anesthesia machine after the machine checkout is complete.

10. Perform Leak Check of the Breathing System

This is the traditional leak check of the breathing system
in which the clinician occludes the Y-piece, pressurizes the breathing
system with an oxygen flush, and observes the canister pressure to ensure
that the breathing system holds pressure (that is, is leak free).

11. Check Adjustable Pressure-Limiting Valve and Scavenging
System

Following the leak check of the breathing system, most
clinicians depressurize the circuit by removing their finger from the Y-piece.
The 1992 Checkout Recommendations, however, suggest that, instead, the
Y-piece should be kept occluded; the adjustable pressure-limiting (APL),
or 'pop-off', valve be opened; and the pressure be allowed to dissipate
through this valve into the scavenging system. Though rare, should the
APL fad to open properly, gas cannot escape from the breathing system,
which creates a closed system and, thus, potential for excessive inspiratory
and expiratory airway pressures and resultant barotrauma.

The latter half of this step is checking the scavenging
system. Like the malfunctioning APL valve, an obstruction in the scavenging
system can also create a closed system and increase airway pressures, which
may result in cardiovascular compromise and barotrauma. Similarly, malfunction
of the negative pressure relief mechanism in an active (that is, vacuum)
scavenging system can transmit negative pressure back to the patient, which
may cause negative pressure pulmonary edema. To detect this malfunction,
the APL valve is opened fully to a properly connected and set scavenging
system. Breathing system pressure should not increase or decrease significantly
when the oxygen flow is minimal or when the oxygen flush valve is kept
open. A malfunction in the scavenging system is indicated by either excessively
high or subatmospheric pressure.

12. Test Ventilator Systems and Unidirectional Valves

By attaching a second breathing bag to the Y-piece to
simulate a patient's lungs, proper cycling of the mechanical ventilator
and proper flow of gas through the breathing system, including proper function
of the unidirectional valves, are checked. If the ventilator bellows progressively
collapses during this step, suspect a leak in the ventilator hose, or other
problem with the bellows assembly. Make sure the second breathing bag (simulated
lungs) is supported by holding the Y-piece. Squeezing the bag during this
check allows gas to escape through the ventilator pressure relief valve,
and the ventilator bellows will not ascend to its baseline position, which
creates the appearance of a ventilator hose leak when actually there is
none. Flow of gas through the breathing system is also checked in the "bag'
mode.

13. Check, Calibrate, and/or Set Alarm Limits of all Monitors

The intent of the Checkout Recommendations is to verify
that the anesthesia machine is functioning correctly. Because of the large
variety of different makes and models of monitoring instruments currently
used in anesthesia practice, specific recommendations for checking each
monitoring instrument is beyond the scope of this document. Nonetheless,
properly functioning monitoring instruments is a prerequisite for the 1992
Checkout Recommendations to be valid. Checks of the monitoring instruments
and any necessary calibration should be conducted daily or according to
manufacturers' specifications.

14. Check Final Status of Machine

The user sets the controls of the anesthesia machine so
that it is ready for clinical use.

Dr. Good is from the Department of Anesthesiology, University
of Florida, Gainesville. Address correspondence to: Editorial Office, Department
of Anesthesiology, University of Florida College of Medicine, Gainesville,
FL 32610-0254.

Reference

1. March MG, Crowley JJ. An evaluation of anesthesiologists'
present checkout methods and the validity of the FDA checklist, Anesthesiology
1991;75:724-729

E. S. (Rick) Siker, M.D. assumed the newly created position
of Executive Director of the Anesthesia Patient Safety Foundation in July
and was officially welcomed at the APSF annual meeting in New Orleans October
16.

Dr. Siker completed his undergraduate education at Duke
University and received his M.D. degree from New York University. Training
in anesthesiology at Mercy Hospital, Pittsburgh, and a research fellowship
in internal medicine at the University of Pittsburgh were followed by a
year as faculty in the Department of Anaesthetics, University of Wales,
Cardiff. Dr. Siker, Chairman of the Department of Anesthesiology at Mercy
Hospital from 1962 through 1992, was the founding Secretary of the Anesthesia
Patient Safety Foundation.

Dr. Siker was President of the ASA in 1973, presented
ASA's Rovenstine Lecture in 1981 and received ASA's Distinguished Service
Award in 1983. He served as Secretary-Treasurer and then President of the
American Board of Anesthesiology, was the first President of the Association
of Anesthesia Program Directors and chaired the Executive Committee of
the World Federation of Societies of Anesthesiologists. Dr. Siker was elected
to Honorary Fellowship in the Faculty of Anaesthetists of the Royal College
of Surgeons of England in 1976 and of Ireland in 1988.

He has been a Visiting Professor at more than 90 Medical
Schools in the United States and abroad, has presented numerous eponymous
lectures, and has authored more than 80 publications. His special research
interests have included narcotics, pain pathways, and anesthesia equipment.
He derives great pleasure from the achievements of more than 200 anesthesiologists
who received their training in his department. Most recently, his principal
interests have been concerned with the many facets of patient safety. The
APSF is delighted to have Rick as its Executive Director.

One of the big factors affecting patient safety today
is the problem of the substance-abuser being allowed to continue to administer
anesthetics and to be responsible for patients' lives. I have been at institutions
(hospitals) in my career, where I had become aware that the CRNA was abusing
drugs while administering a general anesthetic. Needless to say, the rest
of the staff learned what happened and the person, usually a repeater,
would be sent off to the rehab place on a little six week vacation, and
then returned to the fold. In discussing this situation with peers, most
of us felt we would not even let these CRNAS put us to sleep, let alone
anyone we loved. You are always aware of your drugs, too, when these people
relieve you (that is if you feel comfortable enough to let them). With
the repeat abusers also signing your charts, they may involve you in any
liability on their parts also. I believe substance abusers in the medical
field, who have been in a high position of trust and who have accessibility
to narcotics, etc., should go to 0 just like we insist our common folk
do after being caught in possession of marijuana or cocaine. I also believe
that part of the anesthesia consent should be to inform the patient that
the CRNA and/or anesthesiologist was a former substance abuser.

Another situation that I feel needs looking into is the
preparation of the patient for colonoscopy and gastroscopy. In many hospitals
these days, the patients are given sedation during these procedures, having
IV's started, and being monitored for BP, HR, and oxygen saturation. Yet,
these patients who are done as outpatients have no lab work, EKG, or chest
film. Not all of these patients are classified ASA 1. The risk is that
patients come in who are in poor health and former CABG patients with no
labs or EKGs. I feel more needs to be done to address that issue. These
procedures are indeed stressful to these patients and proper lab work and
at least an EKG would serve as a beneficial guideline to prepare for anything
unforeseen happening.

Expansion of the eligibility for APSF sponsored safety
research grants occurred at the Annual Meeting in October.

In August of 1992, the directors of all anesthesiology
residency programs received notice of APSFs "Young Investigators Award.'
The grants of $18,000 will be awarded to successful candidates who will
pursue the six month "Clinical Scientist Track' of the CA-3 year in research
related to anesthesia safety. An application form accompanied each letter.

In response to numerous queries about the availability
of such support during a 'true fellowship' or CA-4 year, the issue was
discussed at the October meeting of the APSF Board of Directors. At that
time, modification of the specifications for the grant was unanimously
adopted and they now include six months of research in either the CA-3
or CA-4 year.

The Anesthesia Patient Safety Foundation Newsletter
is the official publication of the nonprofit Anesthesia Patient Safety
Foundation and is published quarterly at Overland Park, Kansas. Annual
membership: Individual $25.00, Corporate $500.00. This and any additional
contributions to the Foundation are tax deductible. @Copyright, Anesthesia
Patient Safety Foundation, 1992

The opinions expressed in Ns newsletter are not necessarily
those of the Anesthesia Patient Safety Foundation or its members or board
of directors. Validity of opinions presented, drug dosages, accuracy and
completeness of content are not guaranteed by the APSF.